<!DOCTYPE html>
<html lang="en">
	<head>
		<meta charset="utf-8" />
		<!-- Always force latest IE rendering engine (even in intranet) & Chrome Frame
		Remove this if you use the .htaccess -->
		<meta http-equiv="X-UA-Compatible" content="IE=edge,chrome=1" />
		<title>index</title>
		<meta name="description" content="" />
		<meta name="author" content="Base Datos" />
		<meta name="viewport" content="width=device-width; initial-scale=1.0" />
		<!-- Replace favicon.ico & apple-touch-icon.png in the root of your domain and delete these references -->
		<link rel="shortcut icon" href="/favicon.ico" />
		<link rel="apple-touch-icon" href="/apple-touch-icon.png" />
		<script type="text/javascript" src="Javascript.js"></script>
        <style type="text/css">
body{
	margin-top:1px;
	font-family:Arial, Helvetica, sans-serif;
	color:#51555C;
	height:100%;
	background:url(../img/pasci.jpg);
	font-size:16px;
}
#div-regForm,.registered{	
	border:1px solid #eeeeee;
	padding:15px;
	color:#203360;
	
	margin:30px auto 40px 25px;
	width:450px;
}


</style>
	</head>
<body>
    <div id="div-regForm">
    <div class="form-title" align="center" >
      <h1>Historia Clinica</h1></div>
<form name="formulario" action="../procesa/procesa_paciente.php" method="post">
  <table border="0">
            	<tr>
            		<td width="175" height="32">Codigo historia clinica:</td>
                    <td width="236">
            		<input name="fcodpac" type="text" size="38"/>
                    </td>
          		</tr>
				<tr>
					<td height="29">Codigo Paciente:</td>
					<td>
						<input name="fnombre" type="text" size="38" />
					</td>
				</tr>
				<tr>
					<td height="27">Alcohol:</td>
					<td>
						<input name="fpaterno" type="text" size="38" />
					</td>
				</tr>
				<tr>
					<td height="26">Tabaco:</td>
					<td>
						<input name="fmaterno" type="text" size="38" />
					</td>
				</tr>	
				<tr>
					<td height="32">Medicamentos:</td>
					<td>&nbsp;</td>
				</tr>	
				<tr>
					<td height="29">Alergias:</td>
					<td>
						<input name="flugnac" type="text" size="38" />
					</td>
				</tr>	
				<tr>
					<td height="30">Patologias Previas:</td>
					<td>
						<input name="fedad" type="text" size="38" />
					</td>
				</tr>
				<tr>
					<td height="31">Tratamientos Estetido Previo:</td>
					<td>
         			   <p>
         			     <input name="fedad2" type="text" size="38" />
                    </p></td>
				</tr>	
				<tr>
					<td height="40">Fecha ultima menstruacion:</td>
					<td><select name="day">
					  <option value="0">Dia:</option>
					  <?php 
						for($i=1;$i<=31;$i++)
						echo "<option>".$i."</option>";						
						?>
					  </select>
                      <select name="month">
                        <option value="0">Mes</option>
                        <?php 
						for($i=1;$i<=12;$i++)
						echo "<option>".$i."</option>";						
						?>
                      </select>
                      <select name="year">
                        <option value="0">Año:</option>
                        <?php 
						for($i=1940;$i<=2010;$i++)
						echo "<option>".$i."</option>";						
						?>
                    </select></td>
				</tr>	
				<tr>
					<td height="31">Fecha ultimo embarazo:</td>
					<td><select name="day2">
					  <option value="0">Dia:</option>
					  <?php 
						for($i=1;$i<=31;$i++)
						echo "<option>".$i."</option>";						
						?>
					  </select>
                      <select name="month2">
                        <option value="0">Mes</option>
                        <?php 
						for($i=1;$i<=12;$i++)
						echo "<option>".$i."</option>";						
						?>
                      </select>
                      <select name="year2">
                        <option value="0">Año:</option>
                        <?php 
						for($i=1940;$i<=2010;$i++)
						echo "<option>".$i."</option>";						
						?>
                    </select></td>
				</tr>	
				<tr>
					<td height="32">Metodo anticonceptivo:</td>
					<td>
						<input name="focupacion"type="text" size="38" />
					</td>
				</tr>	
				<tr>
					<td height="29">Sist. cardiaco:</td>
					<td>
						<input name="fcelular" type="text" size="38" />
					</td>
				</tr>	
				<tr>
					<td height="32">Sist. respiratorio:</td>
					<td>
						<input name="ftelefono" type="text" size="38" />
				  </td>
				</tr>	
				<tr>
					<td height="31">Sist. 
					  
			      Gastrointestinal:</td>
					<td>
						<input name="femail" type="text" id="femail" size="38" />
					</td>
				</tr>
				<tr>
					<td height="63"><input type="button" onClick="validar();" value="ENVIAR"/></td>
				  <td><p>
				    <input  type="reset"  value="LIMPIAR"/>
				  </p>
			      <p>&nbsp;</p></td>
				</tr>
			</table>
</form>
		<div id="error">
			<?php
 		echo " ";
		?>
		</div>
		
</body>
</html>